Wise Diagnostic Blood and/or Stool Testing Includes:

Test Kit
Test Results
Consultation Review

Full Name *

Email *

Phone *

Date of birth *

Digestive Symptom Problems (Select All That Apply) *

Abdominal pain or cramping

acid reflux or GERD

Belching

Black Stool

Constipation

Diverticula (intestinal pockets)

Abdominal bloating

Bad Breath

Bitter taste in mouth

blood in stool

colitis or crohns disease

diarrhea

excessive appetite

foul smelling stool

frequent laxative use

gallstones

gurgling in stomach

hemorrhoids

indigestion

IBS

Mucus in stool

parasites

stomach acidity

frequent or erratic Bowel movements

Gas( flatulence )

Hard stool

hiatal hernia

intestinal polyps

loose stool

nausea

poor appetite

stomach pain or cramping

Ulcers

Vomiting

None of the above

Other Digestive issues you would like to discuss? If none, please say none *

Frequency of bowel movements *

Shipping Address *

State *

City *

Postal code *

Do you currently have an active membership with us? *

Yes, please use my card on file

No, please use the card information below

Credit Card # *

Expiration date *

CVC / Security code *

Billing Zip Code *

Test Kits are shipped directly to patients to collect samples in the privacy of their own home. Patients will receive instructions on collection and sending in their samples with a prepaid label to the lab.